Dialectical Behavior Therapy (DBT)
The treatment itself is based largely in behaviorist theory with some cognitive therapy elements as well. There are two essential parts of the treatment, and without either of these parts the therapy is not considered "DBT adherent."
1. An individual component in which the therapist and client discuss issues that come up during the week following a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally.
During the individual therapy, the therapist and client work towards improving skill use. Often, skills group is discussed and obstacles to acting skillfully are addressed.
2. The group, which ordinarily meets once weekly for about 2-2.5 hours, in which clients learn to use specific skills that are broken down into 4 modules: core mindfulness skills, emotion regulation skills, interpersonal effectiveness skills and distress tolerance skills.
The four modules
The essential part of all skills taught in skills group are the core mindfulness skills.
Observe, Describe, and Participate are the core mindfulness “what” skills. They answer the question, “What do I do to practice core mindfulness skills?”
Non-judgmentally, One-mindfully, and Effectively are the "how" skills and answer the question, “How do I practice core mindfulness skills?”
Mindfulness comes from the Zen tradition and can be read about in more detail in the book The Miracle of Mindfulness by Thich Nhat Hanh ISBN 0807012394 (among others).
Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Borderline individuals frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing her own situation.
This module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect.
Most approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.
Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although the stance advocated here is a nonjudgmental one, this does not mean that it is one of approval: acceptance of reality is not approval of reality.
Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus willfulness.
Borderline and suicidal individuals are emotionally intense and labile – frequently angry, intensely frustrated, depressed, and anxious. This suggests that borderline clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:
- Identifying and labeling emotions
- Identifying obstacles to changing emotions
- Reducing vulnerability to “emotion mind”
- Increasing positive emotional events
- Increasing mindfulness to current emotions
- Taking opposite action
- Applying distress tolerance techniques
The Miracle of Mindfulness by Thich Nhat Hahn ISBN 0807012394 Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan ISBN 0898620341